Cancer Pain Management & Palliative Care

The physical pain in cancer is invariably interwoven with psychological suffering, social isolation and spiritual overlay.

Dr P Saraswathi Devi

Cancer is the fourth common cause of disease related mortality and more than five million people are suffering from cancer worldwide. Currently in India, over two million people are suffering from cancer, of which more than 80 per cent (1.6 million) reach the treatment centre in advance stages, when the cancer is incurable. This may be mainly due to lack of awareness about the disease (illiteracy), long distances to reach a hospital for early diagnosis and treatment (poverty), more compliant to traditional healing, faith healing, unscientific treatment practices and in case of educated lot, ambivalence to consult a doctor. This vast magnitude requires cancer pain relief and palliative care. As far as patients with advanced cancer are concerned, more than 80 per cent of them experience severe pain and 30-60 per cent of them moderate to severe pain during active therapy. The physical pain in cancer is invariably interwoven with psychological suffering, social isolation and spiritual overlay. At this juncture, these patients become complicated and challenging to medical doctor. This calls for a holistic approach involving other healthcare professionals like nurses, social workers, clinical psychologists, pharmacists, physiotherapists, spiritually empowered persons and volunteers to improve quality of life and also quality of death which is the central focus of palliative care.

Palliative care professionals should pay a tribute to Dame Cecily Saunders, founder of St Christopher's Hospice, London, UK who had first started administering strong opioids and adjuvant medication to relieve pain and distressing symptoms in the incurable cancer patients as early as in 1967. Her strong belief of nature of humanity has lead to a standard of care to unfortunate suffering lot and the development of palliative care units and hospices worldwide.

What is Pain?

Pain is defined as 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage'. It is important to stress the emotional experience with pain in understanding the treatment of pain. Pain in cancer may originate from pressure from a mass, obstructed viscous, nerve involvement, bone involvement or effects of treatment such as surgical scarring, post radiotherapy or chemotherapy side effects.

Cancer pain management starts with the assessment of physical and psychological components of pain by measurement tools like visual analogue scale or verbal rating scale and McGill's pain questionnaire etc. Cancer pain is pathologically classified into nociceptive pain and neuropathic pain.

Nociceptive pain is well defined, well localised and responds to non steroidal, non opioid and opioid analgesics. On the other hand, neuropathic pain results from injury to the pain conducting nervous system and presents with sensation of electrical tingling, numbness, shooting or burning in nature. Most of the time pain is continuous, long and quite resistant to simple analgesic regimen needs adjuvant analgesics. A lot of empathy and a holistic approach include physical therapies, psychological interventions, neuroleptic techniques, nerve blocks; counter stimulation techniques and ongoing support are essentially required for effective management of these difficult pain situations.

Adjuvant analgesics include cortico steroids, antidepressants, membrane stabilisers - anticonvulsants, anti arrhythmic, and N-Methyl-D-Aspartate blockers (ketamine).

These drugs are given orally (convenient and inexpensive), on a regular time schedule, suited to individual to achieve pain reduction at night, at rest during the day and on movement. These drugs are given subcutaneously through syringe drivers in case of patients with swallowing difficulties. Anaesthetists practice the other routes of drug administration like continuous spinal or epidural implantable drug delivery system, local nerve blocks to achieve good pain relief for cancer pain.

The strong opioid analgesics available in India are oral morphine preparations and transdermal fentanyl patches (expensive) -cornerstone for the management of cancer pain world over. It relieves pain, improves rest, sleep, physical activity, appetite leading to good quality of life. The common side effects like nausea, vomiting, constipation, itching can be managed pharmacologically. The fear of addiction, respiratory depression, hastening death with oral titrated preparations of morphine is unfounded is also just a myth. Cancer pain can be managed effectively with simple awareness and commitment amongst healthcare professionals with belief that 'You matter because you are you and you matter to the end of your life, we will do all we can, not only to help you die peacefully but to live until you die'.

The writer is Professor & Head Department of Anesthesiology & Palliative Care Kidwai Memorial Institute of Oncology Bangalore
E-mail: saraswathidevi@sify.com